Nms Surgery Breast Disorders

Front 1

Breast cancer treatment for stage 0,I,II?

Back 1

Stage 0-I with small <1cm tumors: lumpectomy, ax sampling, rad, hormonal tx if ER+
Stage I with larger 1-2 cm tumors: lumpectomy, sentinel node biopsy, rad, hormonal tx + chemo if ER+ and premenopausal
Stage II: same as stage I + option for radical mastectomy (no rad).

Front 2

Breast cancer treatment for stage III, IV?

Back 2

Stage III: Must get preop chemo and MRI for surgical planning (usually modified radical mastectomy) + further chemo and rad
Stage IV: chemo + Pall rad + surgery if painful/infected

Front 3

Breast cancer staging/ metastatic workup?

Back 3

CBC, LFTs, AlkPhos, Ca, Tbili, CT chest+liver, bone scan, renal function.

Front 4

When to get MRI?

Back 4

Surgical planning of advanced breast ca, poor renal function, evidence of spinal/brain mets (steroids, cord decompression, radiation, surgery if possible)

Front 5

What drugs can cause gynecomnastia?

Back 5

Diuretics, estrogens, INH, marijuana, digoxin, alcohol

Front 6

Important risk factors for breast ca?

Back 6

Prev Hx, Fam Hx, Older age, ovarian or endomet ca Hx, older first full-term pregnancy, oophorectomy, obesity, rich N. American, Hx of fibrocystic dz, single, urban, white, early menarche and late menopause

Front 7

Screening recommendations for breast ca?

Back 7

Non high risk: monthly self exams @ 20, professional breast exam 20-39 q 2 years, yearly after 40, mammograms q 1-2 years 40-50, yearly after 50
High risk: monthly self exams @ 20, professional breast exam q 6 mo at 25 and onward, mammogram q1-2 years at 30-40, yearly after 40

Front 8

false neg rate of mammograms?

Back 8

7-20%

Front 9

BIRADS 0-5 definitions?

Back 9

0: Needs additional eval
1: Normal
2: benign, recommend routine screening
3. Prob benign, recommend 6 mo followup
4. Suspicious, recommend biopsy
5. Highly suggestive of malignancy

Front 10

Diff b/w screening and diagnostic mammography?

Back 10

1. screening cranio-caudal and mediolateral oblique views. Diagnostic is these views plus mediolateral and lateromedial
2. Diagnostic can do magnification mammography

Front 11

Types of calcifications on mammogram that are suspicious of malignancy?

Back 11

Pleomorphic, heterogeneous, fine/linear/branching

Front 12

2 entities that look like DCIS histopathologically but have higher cancer risk?

Back 12

sclerosing adenosis, atypical ductal hyperplasia

Front 13

Treatment for fibrocystic dz?

Back 13

Elimination of caffeine, VitE supplement, cyst aspiration, f/u in 3 mo

Front 14

What could a 14cm mass in young woman be?

Back 14

Cystosarcoma phyllodes: large, occasional ulceration of skin. Excise w/ generous margins

Front 15

Most common cause of bloody discharge and treatment?

Back 15

Intraductal papilloma: Mammography + ductogram + excision

Front 16

Prognostic indicators in BC?

Back 16

Histologic type: IDC, ILC, inflammatory carcinoma worse than tubular, papillary, mucinous, or Paget's, +ER=better prog, aneuploidy=worse prog, Ki-67+ (higher S phase fraction or mitotic index)= worse prog, Her-2-Neu+ (human epidermal growth factor receptor)= worse prog and shorter relapse time, younger at diagnosis tend to do worse

Front 17

What does inflammatory carcinoma of the breast look like?

Back 17

Ulcerated, edema of breast, peau d'orange, retraction of skin

Front 18

What does retraction of skin overlying mass mean?

Back 18

suggests invasion of breast support structures and lymphatics. worse prognosis.

Front 19

what do you do when fluid cysts recur?

Back 19

excise cyst to rule out cancer. prog depends on path

Front 20

What does it mean when mass is fixed to deeper tissues?

Back 20

Invasion to tissue outside breast=worse prognosis

Front 21

Significance of LN palpable in supraclavicular area?

Back 21

=distant met. M1= stage IV. unresectable and incurable

Front 22

Arm edema means?

Back 22

obstruction of axillary lymphatics= worse prognosis

Front 23

What to do with crusty lesion in nipple?

Back 23

1. Biopsy nipple lesion and subareolar mass to rule out Paget's dz
2. If Paget's + and confined to nipple then excision of nipple areolar complex or primary radiotx.
3. If underlying DCIS excision and radiotx

Front 24

Surgical principles in mgmt of BC? What does it mean if you have >10 LN involved?

Back 24

1. establish diag
2. Completely eradicate primary tumor
3. regional nodes or distant mets?
4. wide excision + radiation good for localized tumor with clear margins
5. Mastectomy usually for larger/multicentric tumors
6. Removal of axillary LNs are for staging not tx
7. Decrease in survival correlates with increase in # of LNs involved
poor prog: >10 LNs=10 year survival of 14%
8. Systemic adjuvant tx in BC with axillary node involvement decreases risk of recurrence by 30%

Front 25

Blood supply to breast?

Back 25

Arterial: Internal mammary (thoracic) and lateral thoracic
Venous: Axillary and internal mammary V

Front 26

Lymphatic drainage of breast? Divisions?

Back 26

Axillary LN chain.
Level I: lateral to pec minor
Level II: posterior to pec minor
Level III: Medial to pec minor

Front 27

Radical mastectomy?

Back 27

Removal of breasts, skin, pec major and minor, axillary LNs. Only for tumors that extend into muscle

Front 28

Modified radical mastectomy?

Back 28

spares pec major and minor

Front 29

Auchincloss modification?

Back 29

spares pec minor

Front 30

Patey modification?

Back 30

transection of pec minor and dissection of level III nodes

Front 31

Simple mastectomy?

Back 31

removal of breast, nipple-areolar complex, skin. Usually for LCIS and DCIS

Front 32

When to radiate after mastectomy?

Back 32

1. tumors >5cm that involve margin of resection or invate pec fascia or muscle
2. Axillary radiation when >4LN involved
3. Rad of internal mammary nodes if apparent on sentinel node imaging
4. Supraclavicular nodes if extranodal extension into axillary fat

Front 33

Limits of dissection for mastectomy?

Back 33

Clavicle, Lat, costal margin, lateral border of sternum

Front 34

Lumpectomy? Segmental mastectomy?

Back 34

For <5cm solitary tumors
1. removal of primary lesion with clear margins
2. axillary node sampling
3. local radiotx to the breast
4. Radiotx to axillary, internal mammary, or supraclavicular nodes if >4 nodes are positive or + extracapsular invasion
Note: radiation after lumpectomy greatly reduces chance of local recurrence

Front 35

Does lumpectomy with rad affect survival rates?

Back 35

Not compared to mod radical mastectomy in stages I and II.

Front 36

Tumor staging

Back 36

table 11-6 p. 330 memorize

Front 37

What measurements do you need for staging?

Back 37

Tumor size, LN biopsy and histology

Front 38

What is standard method for LN biopsy?

Back 38

Remove nodes at levels I and II

Front 39

How do you do a sentinal node biopsy?

Back 39

1. Inject dye or radiotracer around primary tumor
2. wait for dye or tracer to reach node
3. take it out and perform histology

Front 40

If sentinel node is negative for tumor, what are the chances that other nodes are negative?

Back 40

>90%

Front 41

Most physicians do not advocate mod radical mastectomies for tumors less than what?

Back 41

<2cm

Front 42

Does radiation increase survival?

Back 42

No, only decreases local recurrence

Front 43

2 contraindications to radiation tx

Back 43

1. Prior radiation to chest or breasts
2. connective tissue dz

Front 44

4 Methods of breast reconstruction?

Back 44

TRAM (transverse rectus abdominus myocutaneous flap), Lat flap, DIEP (Deep inferior epigastric perforator) flap, free flap

Front 45

Flaps not as successful in which patients?

Back 45

Obese and smokers

Front 46

Contraindications for mastectomies?

Back 46

1. Primary lesions involving chest wall
2. extensive local or regional disease
3. stage III or IV cancer

Front 47

Mgmt of stage 0 and I BC with <1cm tumors? (no nodes)

Back 47

Lumpectomy+axillary sampling+radiation+hormonal Tx if ER positive like aromatase inhibitor or Tamoxifen

Front 48

At what stage BC do you check for mets?

Back 48

Stage I

Front 49

What's the workup for mets?

Back 49

CXR for lung and bone mets, Liver enzymes for liver mets, bone scan and/or head CT if bone pain or neuro complaints, abdominal CT if liver enzymes or bilirubin or alk phos is abnormal

Front 50

Mgmt of stage I with larger (1-2 cm) tumor and no nodes?

Back 50

Lumpectomy+axillary sampling + radiation+ hormonal tx if ER + + chemo only if premenopausal

Front 51

Mgmt of stage II?

Back 51

Lumpectomy+axillary sampling + radiation+ hormonal tx if ER + + chemo if node positive or premenopausal w/node negative (table 11-8 p.342)

Front 52

Chemo is poorly tolerated in what population?

Back 52

elderly

Front 53

Who responds better to chemo?

Back 53

Premenopausal pts

Front 54

Who responds better to hormonal tx?

Back 54

postmenopausal

Front 55

Follow-up surveillance protocol for Stage I and II?

Back 55

1. see physician 2x/yr
2. annual CXR +LFTs
3. If lumpectomy mammogram that breast q 6mo for 2 years then annually
4. If mastectomy mammorgram the other breast, dunno freq

Front 56

After mastectomy what are the changes of Ca dev in remaining breast?

Back 56

15%

Front 57

Stage I 5 year survival rate?

Back 57

93%

Front 58

Stage II 5 year survival?

Back 58

72%

Front 59

Mgmt of Stage III BC?

Back 59

1. Consult oncology for neoadjuvant chemo (before surg)
2. surgery

Front 60

Mgmt of stage IV BC?

Back 60

palliative radiation and chemo. surgery only reserved for local control of primary tumor (painful or infected)

Front 61

Imaging modality to plan for surgery?

Back 61

MRI

Front 62

Stage III 5 year survival?

Back 62

41%

Front 63

Stage IV 5 year survival?

Back 63

18%

Front 64

Breast mass with cellulitis and edema =?

Back 64

Inflammatory carcinoma

Front 65

Tx for inflammatory carcinoma?

Back 65

1. Staging workup: CBC, liver enzymes, alk phos, Ca, Tbili, CT chest, bone scan, CT liver w contast or MRI w/ gadolinium if poor renal function
2. chemo
3. modified radical mastectomy
4. adjuvent chemo
5. hormonal tx for ER +
6. radiation for chest and regional LN basins

Front 66

What should you do if you have pathological fracture from cancer?

Back 66

Due to bony mets, control the cancer locally with radiation and orthopedic repair. radiation shouldn't interfere with fracture union

Front 67

If after diag of BC you get neuro sxs like decreased sensation or motor function, what do you do?

Back 67

MRI, steroids, cord decompression, radiation

Front 68

If after diag of BC you get new seizures, what do you do?

Back 68

CT/MRI to diagnose brain mets, immediate steroids to decrease ICP, surgery or irradiation

Front 69

Coma/confusion with hx of BC could be what?

Back 69

Acute hypercalcemia due to bony mets or PTH-related peptide release (usually BC or LC)

Front 70

Antibiotics for Mastitis?

Back 70

Dicloxacillin/Cefalexin (usually S.aureus or coag neg staph)

Front 71

If a mastitis doesn't heal with abx, what are we worried about?

Back 71

Inflammatory carcinoma

Front 72

Mgmt of BC in pregnancy?

Back 72

Stage I and II mastectomy or lumpectomy w radiation after birth is safe. Lumpectomy discouraged in early pregnancy because of need for radiation.
Stage III and IV: rapid radiation and chemo. may need to abort.

Front 73

Is ER or prog status reliable during pregnancy?

Back 73

NO

Front 74

What do you do for breast mass in a man?

Back 74

Mammogram to diff gynecomnastia from cancer, mastectomy and radiation

Front 75

When do men usually present with BC?

Back 75

after 60. Tend to present at later stage

Front 76

What can cause gynecomnastia?

Back 76

Diuretics, estrogens, INH, Weed, Dig, EtOH

Front 77

Most common sites of metastasis?

Back 77

Lungs, liver, bone, brain, ovaries

Front 78

How to biopsy bc?

Back 78

Core needle biopsy